Principles for Medical Treatment

CHAPTER 7: PHARMACOLOGICAL TREATMENT OF ADHD

Principles for Medical Treatment

Seventeen Considerations in Medication Selection in the Treatment of ADHD209

1. Age and individual variation 2. Duration of effect 3. Speed of action of the medication 4. ADHD clinical presentations 5. Comorbid symptom profile 6. Comorbid psychiatric disorder 7. History of family medication use 8. Attitudes towards medication use 9. Affordability 10. Medical problems and other medications 11. Associated features similar to medication side effects 12. Combining stimulants with other medications 13. Potential for misuse/diversion 14. Physician attitude towards ADHD medications 15. A first-line treatment represents a balance of efficacy, tolerability and clinical support and is approved

by Health Canada 16. Second-line treatments are medications approved by Health Canada but have lower efficacy rates 17. Third-line treatments are reserved for situations where first-line and second-line treatments have not

worked and are usually off-label medications.

1. Age and individual variation All ADHD medications can be used for all age groups, although not all medications have received the "official" approval for various ages through the process required by the Therapeutic Products Directorate (TPD) of the Canadian government. Treatment before the age of six, if necessary, should only be done under the direction of a specialist262 or in consultation with a specialist. There is no maximum age to treat ADHD if the general health of the patient permits use of those treatments. Women of childbearing age taking ADHD medications should be advised to talk with their physicians if they plan a pregnancy, as effects of ADHD medications on the foetus, and on the baby while breastfeeding, are unknown. Individual variation may exist (e.g. effective dosage is not closely correlated with age, weight or symptom severity), accounting for differences in treatment response and wide variation in dosage requirements. Medications don't work equally well for all patients ? for some, results are huge; for others, substantial, but not huge; for others, much more modest; and for a few, currently available medications don't work very effectively at all, even when different classes of drugs are tried. Caution: clinicians should not oversell the effectiveness of medications. Some patients may experience difficulty swallowing pills. Although this can be improved by training, it should also be noted that some medication can be sprinkled on soft food or diluted in water.

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2. Duration of effect

Exposure to tasks that require mental effort changes over the years. Medication use can be titrated to meet increased demands or to cover longer periods of daytime impairment. When considering duration of medication, it is important to remember that ADHD impacts all aspects of the child, adolescent and adult's life on a daily basis, not just the classroom or workplace. Learning also takes place outside of school and work. The severity and complexity will vary from individual to individual and developmental stages and ages.

However, as mentioned in previous chapters, areas often significantly affected causing impairment include: social functioning (interpersonal relationships, marriage and family life); emotional functioning (selfesteem, anxiety mood); recreational activities (sports, hobbies, etc.); physical exercise; sleep patterns; eating habits; participation in risky, impulsive behaviours (unprotected sex, unplanned pregnancies, HIV, driving and other accidents, SUD, etc.); physical health (poor adherence to medication and follow-up for other medical conditions); and other areas. Therefore it is important not only to optimize treatment for core symptoms and to minimize side effects but, in order to improve the overall quality of life for most individuals of all ages, the duration of medication should extend beyond the classroom/work settings into the p.m. and also include weekend and holidays. Similarly, a patient may need to have individualized treatment based on day-to-day variation. This may be critical for tasks such as driving, where the maximal risk period for young drivers is during the evenings and at weekends. Duration of effect can vary from patient to patient. Clinical experience indicates that, for some patients, duration of effect is shorter or longer than what is indicated in the product monograph.

3. The speed of action of the medication

When patients require urgent treatment, psychostimulants are the treatments of choice. However, ADHD is a chronic disorder where long-term management approaches are critical. For ADHD patients in general, ADHD is often perceived as an emergency once it is identified, and faster is seen to be better. However, given the extraordinary rates of low adherence over a year, long-term benefits are more likely if the ultimate goal ? once emergencies such as abuse or expulsion from school are dealt with ? is not just to obtain reduction of symptoms and better quality of life but also to support long-term adherence by taking into account patient side effects and comfort.

4. ADHD presentations

The core symptoms within ADHD (that also determine the presentations) include inattentiveness, impulsivity and motor hyperactivity. All three of these symptoms are associated with impairment of different sorts. For example, attention problems remain stable and impairing throughout the lifespan and affect academic and organizational functioning. Hyperactivity may diminish in adolescence but is transformed into restlessness, driven behaviour, stimulus-seeking behaviour, and discomfort from always being on the go. This may continue well into adulthood. While adults may present with impairing inattentive symptoms, their childhood progression into adulthood may reveal that some came from an only inattentive background, while others came from a transformation of the combined presentation. It is important to understand the transformation of the clinical symptoms because it may have relevance both in terms of dosing effect as well as emergence of anxiety and other side effects. All of the ADHD medications improve inattention, but not to the same extent.

5. Comorbid symptom profile

The CAP-Guidelines Committee has used a symptom-based inventory to help the clinician determine the possible treatments for each symptom. When comorbid disorders exist, prioritizing the key symptom

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makes the choice of medication simpler and widens the medication options. For example, aggression and irritability may be a part of many of the comorbid disorders the patient has, but focusing on this symptom addresses the major area of impairment. 6. Comorbid psychiatric disorders

When there is a comorbid disorder along with ADHD, it is generally advised that the treatment may be determined by the more severe disorder first CB . A variety of strategies have been used to determine sequence of treatment including diagnostic certainty, patient preference, the primary disorder and the disorder with greatest impairment, or the disorder most likely to respond to treatment CB . However, major mood disorders like depression, bipolar disorders and substance use disorder should be identified and treated prior to ADHD CB . Residual symptoms may require additional treatments. It is important to review drug-to-drug interactions to ensure that there is no risk to the patient. It is not unusual for patients to be on more than one medication to deal with "complex ADHD".

7. Family history of medical treatment

A family history of prior positive medical treatment should also be considered as well as negative experience with a specific medication. Although there is no good research data on these aspects, it is understandable that a positive response to a specific treatment in a family member could increase positive expectations for this treatment while the contrary can occur for a negative outcome.

8. Attitudes towards medication use

All patients and their families need to be educated. The choice of medication should follow the principles of informed consent. Information on informed consent is available in chapter one of the Canadian ADHD Practice Guidelines. Emotional biases against the use of ADHD medications are often due to misinformation regarding side effects and guilt about having `caused' the problem through `bad' parenting. Alternatively, excessive expectation of medication improvement may be present and lead to disappointment. It is important for families to access reliable and valid sources and to rely on parent support groups. Medical treatments are there to facilitate treatment of the patient's full range of concerns. Also, parents that are at risk for diversion (e.g. substance abusers) should not be given short-acting stimulants for themselves or for their children. Patients should be educated about the risks of diversion of medication to friends.

9. Affordability

All patients should have access to optimum treatment. Unfortunately, some medications are beyond the financial reach of a significant number of patients without extended health insurance. Some medications can be supported through special access programs, but access is often limited by the extensive paperwork required and the constricted time for which medication is supplied. Most medications are covered by third party insurers. However, sometimes patients may have to rely on generic medications that may not be as effective. CADDRA continues to advocate for a resolution of this problem at the government level. Clinicians need to be informed about the cost of medications and the patient's coverage or ability to afford them before deciding what to prescribe.

10. Medical problems and other medications

It is important for the clinician to do a thorough medical assessment including physical examination before prescribing medications. The Canadian ADHD Practice Guidelines provide templates that can guide the clinician. Many conditions look like ADHD (e.g. thyroid, hearing deficits, vision problems, etc.). It is important for clinicians to be aware of any medical risk the patient may have that affects suitability for a medication (e.g. blood pressure problems, interactions with other medications, cardiovascular risk, etc.). When in doubt, a specialist referral is indicated.

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11. Associated features similar to medication side effects

All medications may cause side effects. Most side effects settle after two or three weeks of continuous use. One of the most common reasons for non-adherence is related to a lack of physician awareness or understanding of side effects, or patients' reluctance to explain their discomfort. Some pre-existing conditions like tics, sleep problems, very low weight, headaches, GI problems or dysphoria may be aggravated by ADHD medications (although some of these very symptoms might actually be improved by the ADHD medications as well). Patients should be told up front about how to tell if they are getting too much medication, e.g. feeling too "wired", too irritable or too serious during the time medication should be active. In those cases, there is a strong chance that the dose is too high or that the specific medication may not be a good fit for that patient. However, if any symptoms from this triad of too "wired", too irritable or too serious is experienced later in the day, or they are dysthymic at the time when medications would be expected to be wearing off, it is likely that those symptoms are not from an excessively high dose but from rebound, where the medication is wearing off too fast and the patient is "crashing". An understanding of the side effect profile of each medication may afford a better `fit'.

12. Combining stimulants with other medications

When a clinician feels that a second medication is needed, it is suggested to begin with an ADHD medication that is known to combine safely with the second medication. For example, in the selection of an ADHD medication for a patient with severe anxiety disorder, a psychostimulant could be combined with an antidepressant (note: there are some limitations with atomoxetine). Younger children should be referred if this is being contemplated.

13. Potential for misuse/diversion

It is important to be aware of the issue of diversion and misuse associated with psychostimulants. Nonmedical use of prescription stimulants is a growing concern. There are particular groups in society that have misinformation and, in fact, pass on myths that non-medical use of stimulants increase academic performance. As well, other groups use prescription stimulants in hopes to experience euphoria and enhance their experience of partying. The short-acting stimulants have a much higher risk of misuse/ diversion than the longer-acting stimulants. All professionals involved in treating ADHD patients should be alert to the signs of diversion and misuse and consider these behaviours as significant and not benign. (For more information about the signs of diversion and misuse, please see Health Canada 2006, Abuse and Diversion of Controlled Substances: A Guide For Health Professionals).

14. Physician attitude towards ADHD medications

Information on ADHD is rapidly evolving (i.e. understanding of comorbidity, adult ADHD, medical treatments, biological underpinnings, etc). It is imperative that physicians seek out reliable sources of information and continue to upgrade their clinical skills. The CADDRA Guidelines, website, conference, continuing medical education courses and other updates are designed to expose clinicians to the latest advances in assessment and treatment for ADHD across the lifespan. Patients today are often as educated about their health conditions as their doctors, and physicians need to be comfortable working with the knowledgeable patient and/or family. Such comfort can be achieved through an open attitude, experience and quality continuing education.

15. First-line treatments

First-line pharmacological treatments for ADHD are medications that have the best risk-benefit profile; longer duration (diminishes need for multiple dosages and therefore augments compliance, coverage and

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recovery, diminishes diversion, diminishes rebound); effectiveness as measured by effect size; and are Health-Canada approved treatments.

16. Second-line treatments Second-line pharmacological treatments for ADHD are medications that have demonstrated efficacy and are approved for ADHD. They can be used for patients who do not tolerate or respond to first-line treatment, or do not have access to first-line medications. They can also be used as a potential augmentation for first-line treatment responders.

17. Third-line treatments Third-line pharmacological treatments are medications whose use is off-label. They have a higher sideeffect profile and are less efficacious.

ADHD Medication Chart The Canadian ADHD Medication Chart contained in the sleeve of the CAP-G binder provides information on the dosage and appearance of ADHD medications and is a useful tool when discussing medication options with patients and their families. It is available in a Canada-wide and Quebec version on the CADDRA website. The charts were originally developed by the Continuing Medical Education Team at Laval University in Quebec City in collaboration with the organizational committee for the Conference on the Pharmacological Treatment of ADHD in April 2007. This team continues to collaborate with CADDRA to update the medication charts when new medications, changes in indication or in coverage occur. The most recent update is always available at caddra.ca

Specific Medication Selection Guidelines and Monitoring

STEP 1 Feedback and Expectations (refer to Chapter 1, Visit 4 for more details) Use principles of informed consent to ensure the patient is adequately educated when addressing medication questions, particularly regarding degree of efficacy and side effects.

STEP 2 Specific Medication Selection: Considerations One central philosophy within CADDRA is to treat each patient as a unique being and to use the clinical advice within the "Seventeen Considerations for Medication Selection" as the guide.

Practice Point: There are some practical questions that begin the selection process:

a) Is medication indicated in your age group? Generally speaking, the first choice should be a medication that has an approved indication by Health Canada for ADHD within the specified age group. Even though some ADHD medications are not officially approved by Health Canada for a specific age group, doctors may decide to use them based on scientific evidence and expert consensus.

b) What impairment do you have and at what time of the day? Is it mainly during work hours,

meetings, exam times, leisure times, driving periods, morning routines, etc.? Ensure the patient

is medicated when it is necessary and that you understand and are responding to his/her individual

needs.

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